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Health Information Management (HIM) EHR Monitoring

Health Information Management (HIM) EHR Monitoring. EHR for HIM. HIM Monitoring. HIM is responsible for monitoring various reports in the TIU option and PCC TIU Menu Monitoring Reports RPMS Basics. TIU Medical Records Menu Options (TIUM). Individual Patient Document IPD.

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Health Information Management (HIM) EHR Monitoring

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  1. Health Information Management (HIM) EHR Monitoring EHR for HIM

  2. HIM Monitoring • HIM is responsible for monitoring various reports in the TIU option and PCC • TIU Menu • Monitoring Reports • RPMS Basics

  3. TIU Medical Records Menu Options (TIUM)

  4. Individual Patient DocumentIPD

  5. Select TIU Menu for Medical Record Option: SSD Select Status: ALL// ? 1 undictated 5 unsigned 9 purged 2 untranscribed 6 uncosigned 10 deleted 3 unreleased 7 completed 11 retracted 4 unverified 8 amended Enter selection(s) by typing the name(s), number(s), or abbreviation(s). Select Status: ALL// COMP completed Select CLINICAL DOCUMENTS Type(s): Progress Notes// ? 1 Progress Notes 3 Discharge Summaries 5 Laboratory Reports 2 Addendum 4 Clinical Procedures Select SEARCH CATEGORIES: AUTHOR// ? 1 All Categories 5 Patient 9 Title 2 Author 6 Problem 10 Transcriptionist 3 Expected Cosigner 7 Service 11 Treating Specialty 4 Hospital Location 8 Subject 12 Visit Select SEARCH CATEGORIES: AUTHOR//TI Title Please Select the PROGRESS NOTE TITLES to search for: You may choose more than one status by either entering the numbers or status (i.e. 5,6 or uns,uncos) either one would give you unsigned and uncosigned

  6. Select TIU Menu for Medical Record Option: SSD • Select Type – Includes all document classes Select PROGRESS NOTE Type(s): Advance Directive// ? 1 Advance Directive 7 Medicine Service Note Dictate Notes 2 Adv React/Allergy Id Parent Notes Consults 3 Crisis Note Id Child Notes Operative Reports 4 Clinical Warning Pharmacy Notes Deleted Progress Note 5 Sample Titles Nursing Notes Enter selection(s) by typing the name(s), number(s), or abbreviation(s). May select ALL to see all progress notes

  7. Select TIU Menu for Medical Record Option: SSD • Select Category Select SEARCH CATEGORIES: AUTHOR// ? 1 All Categories 7 Service 2 Author 8 Subject 3 Expected Cosigner 9 Title 4 Hospital Location 10 Transcriptionist 5 Patient 11 Treating Specialty 6 Problem 12 Visit • Enter selection(s) by typing the name(s), number(s), or abbreviation(s).

  8. Report of All Progress Notes

  9. Hidden Actions (??) The following actions are also available: + Next screen > Shift View to Right - Previous Screen GO Go to Page FS First Screen RD Re Display Screen LS Last Screen PL Print List UP Up a Line QQ Quick Quit DN Down a Line ADPL Auto Display(On/Off) < Shift View to Left CP Copy CT Change Title CWAD CWAD Display EE Expand/Collapse Entry F Find EX Expand/Collapse Entry

  10. PDM Print Documents Menu • Print Documents Menu • (DEMO WALK-IN CENTER) • PDM1 Discharge Summary Print • PDM2 Progress Note Print • PDM3 Clinical Document Print • Select Print Documents Menu Option:

  11. PDM2 Progress Note Print • Print Documents Menu • (DEMO WALK-IN CENTER) • Select Print Documents Menu Option: Progress Note Print • Select PATIENT NAME: DEMO,PATIENT M 10-01-1947 XXX-XX-1234 4 • No notes on file for DEMO,PATIENT • Press RETURN to continue...

  12. Notes Title Report

  13. To get a list of unsigned notes Select TIU Menu for Medical Records Option: SSD Search for Selected Documents Select Status: ALL// UNS,UNCO unsigned uncosigned Select CLINICAL DOCUMENTS Type(s): Progress Notes// ALL Progress Notes Addendum Discharge Summaries Clinical Procedures Laboratory Reports Select SEARCH CATEGORIES: AUTHOR// ALL All Categories Start Reference Date [Time]: T-7// T-365 (NOV 14, 2005) Ending Reference Date [Time]: NOW// (NOV 14, 2006@08:37) This will list all unsigned and uncosigned notes, addendums, and discharge summaries for all authors.

  14. Report by Author Select TIU Menu for Medical Records Option: SSD Search for Selected Documents Select Status: ALL// 5,6 unsigned uncosigned Select CLINICAL DOCUMENTS Type(s): Progress Notes// ALL Progress Notes Addendum Discharge Summaries Clinical Procedures Laboratory Reports Select AUTHOR: USER,ONE ON LPN Start Reference Date [Time]: T-7// T-365 (NOV 14, 2005) Ending Reference Date [Time]: NOW//

  15. Example of a report by author. Print to provide a copy to provider

  16. View a User’s Alerts (VUA)(Located under TIU Menu for Medical Records) 'View a User's Alerts' Synonym: VUA Displays a user's alert list. Used to compare alert list with MYU list which medical records personnel can see via SSD option. Select TIU Menu for Medical Records Option: vua View a User's Alerts Select NEW PERSON: mouse MOUSE,MINNIE MAA ADP SITE MANAGER 4 alerts found for MOUSE,MINNIE: 1 DEMO,PATI (999999): UNSIGNED GENERAL ENCOUNTER OVERDUE for SIGNATURE. 2 DEMO,PATI (999999): UNSIGNED EMPLOYMENT PHYSICAL OVERDUE for SIGNATURE. 3 DEMO,PATI (D9999): Labs resulted - [GLUCOSE] 4 DEMO,PATI (D9999): Critical lab: GLUCOSE 950 03/09 16:21 Rather than printing the unsigned list, Check to verify they have a pending notification. If so, advise user to process notifications.

  17. Additional TIU options The incomplete chart system is not used in IHS. List of Active Document Titles' Synonym: LAD Displays a list of active titles sorted by document class. Multiple Patient Documents' Synonym: MPD IHS version of report to view documents from multiple patients. Awaiting Signature Listing' Synonym: SIG (inpatient) Use this option to pull a list of charts in the Incomplete Chart system that are waiting for signatures on TIU documents. You can update the Incomplete Chart file here and print out a chart copy of the document. Statistical Reports' Synonym: STR IHS version of Statistical Reports Menu. Contains IHS option and header code. AUT AUTHOR Line Count Statistics DTS Dictation Timeliness Statistics SER SERVICE Line Count Statistics TRA TRANSCRIPTIONIST Line Count Statistics

  18. Unsigned Orders Search (SSD) Unsigned Orders Search (This report is formatted for a 132 column output.) Select one of the following: 1 Released/Unsigned 2 Unsigned 3 Unsigned/Unreleased Enter the type of orders to search: 2 Unsigned Select one of the following: Enter the sort criteria: ? To sort orders by Service/Section enter a 1, by Provider enter a 2, by Patient enter a 3, by Location enter a 4, by Entering Person enter a 5 and by Division enter a 6, Enter an ^ to exit the option. Select one of the following: 1 Service/Section 2 Provider 3 Patient 4 Location 5 Entered By 6 Division Enter the sort criteria: 6 Division Would you like a specific Division? NO// Enter a starting date: t-7 (AUG 21, 2006) Enter an ending date: t (AUG 28, 2006) Print summary only ? NO// DEVICE: HOME//

  19. Pending Consults • Setup HIM at the ALL SERVICES level. • HIM should routinely run the pending consults report for all services to be sure pending consults are being processed and completed correctly.

  20. Service Consults Pending Resolution Select Consult Tracking Reports Option: Service Consults Pending Resolution Select Service/Specialty: ALL SERVICES GROUPER ONLY List From Starting Date: ALL DATES// ...SORRY, HOLD ON...

  21. All Services pending report

  22. Performance Monitor Report Enter starting date: t-30 (JUL 29, 2006) Enter ending date: t (AUG 28, 2006) Do you want ALL providers to appear on this report? Y// ES Select one of the following: A All orders P Pharmacy orders only Select order category: P// All orders Select one of the following: I Inpatient O Outpatient B Both Select patient status: B// oth Select one of the following: S Summary (includes provider details) D Detail (includes order details) B Both (Summary & Detail) Summary Report Totals Only (no provider details) Select report: S// ummary (includes provider details) DEVICE: HOME// VIRTUAL

  23. Performance Monitor Report Example CPRS Performance Monitor - Summary Report Aug 28, 2006 PAGE 1 Selected Date Range: 7/29/06 to 8/28/06 Sort criteria: ALL PATIENTS/ALL ORDERS BREAKDOWN OF ORDERS PROVIDER PROVIDER NOT SELF ENTERED PROVIDER UNIVERSE DEA/STU/POL ORDERS ENTERED % WR/VE/TE/EL -------------------------------------------------------------------------------- PROVIDER,ONE Outpt Tot 16 16 16 100% Sub-tot 16 16 16 100%

  24. PCC Reports • Uncoded Diagnoses/Procedures (ICD) • List Unreviewed/Incomplete Visits (LIR) • Tally of Reviewed/Completed Visits (TUR) • PCC Error Report (VRR)

  25. PCC Uncoded Diagnoses/Procedures

  26. ICD Option

  27. PCC Uncoded Diagnosis/Procedures Select Fix UNCODED ICD9 Diagnoses/Operations Option: POV  Fix Uncoded Purpose of Visit Diagnoses The search for Uncoded V POV's can begin at any date that you specify.  To get all of the uncoded entries enter a really early date like 01/01/1930.  If you want to only review data for visits in the past week, enter T-7. Enter the Beginning Date to Search for Uncoded V POV's:  T-365 (NOV 29, 2006) *Above enter the date you want to start your search*      Select one of the following:           A         ALL Locations/Facilities           S         One SERVICE UNIT'S Locations/Facilities           O         ONE Location/Facility Enter a code indicating what LOCATIONS/FACILITIES are of interest: O// All  ALL Locations/Facilities Searching the V POV File Continue? Y// Y  YES NAME: DEMO,PATIENT  DOB: NOV 30,1952  SEX: F  HRN: 123456 DATE OF VISIT: NOV 29, 2006  15:57  LOC: DEMO HOSPITAL PROVIDER NARRATIVE:  IMMUNIZATION - INFLUENZA POV: .9999// (reading the narrative, you might be able to figure out the correct code. Then enter that code here once that is done, the system will keep bring you all the uncoded diagnosis available from the time frame you selected above). Continue? Y// N  NO All done with the V POV file

  28. List Unreviewed/Incomplete Visits • Reports all visits with a chart audit of incomplete or blank • Visits can be sorted by: • Date • Primary provider • Clinic code • Hospital location (scheduling clinic) • Facility

  29. Tally of Reviewed/Completed Visits • Reports a count of all visits with a chart audit status of incomplete or blank • Visits can be selected and sorted by: • Date • Primary provider • Chart audit status

  30. PCC Error Report • Under PCC, select DEU  SUP VRR TXER, then ALL • In addition to running the Coding Queue Report, you need to run the PCC Error Report weekly.

  31. VRR Visit Review Report

  32. PCC Error Report Example • PCC Data Entry Module • ********************************* • * VISIT REVIEW ERROR REPORT * • ********************************* • Report of Errors for Posting Date Range: JAN 13, 2009 through JAN 13, 2010 • ALL Locations Included • ------------------------------------------------------------------------------- • THE FOLLOWING VISITS DO NOT HAVE EITHER A PRIMARY PROVIDER OR PURPOSE OF VISIT • ------------------------------------------------------------------------------- • HRN FAC: [] HRN: [34-1234] NAME: [DEMO,VERNA] • DATE: [MAR 24,2009@09:00] LOCATION: [PARKER HOSP] • SERVICE CATEGORY: [A] TYPE: [I] CLINIC: [WELL CHILD] • This visit has: PROVIDER's • E102-NO PURPOSE OF VISIT (POV) HAS BEEN ENTERED FOR THIS VISIT

  33. Questions and Discussion

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